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This descriptive study used stakeholder input to prioritize evidence-based strategies for improving depression care and to select incentives for mental health clinicians to adopt those strategies, and to conduct a feasibility test of an incentive-based program in a managed behavioral healthcare organization (MBHO). In two rounds of interviews and a stakeholder meeting, MBHO administrators and clinicians selected increasing combination treatment (antidepressant plus psychotherapy) rates as the program goal; and paying a bonus for case reviews, clinician feedback, and clinician education as incentives. We assessed program feasibility with case review and clinician surveys from a large independent practice association that contracts with the MBHO. Findings suggest that providing incentives for mental health clinicians is feasible and the incentive program did increase awareness. However, adoption may be challenging because of administrative barriers and limited clinical data available to MBHOs.

Nurse leaders need effective communication models to articulate the functions, processes, and activities of health care organizations. This article describes the development and use of a communication model to streamline the dissemination of information to the targeted organizational entities that need it. The model's step-by-step process enhances the broadcasting of information needed to ensure patient safety and promote quality patient care by capturing the components integral to the communication process.

Background: The health-care systems in the USA and Israel differ in organization, financing and expenditure levels. However, managed care organizations play an important role in both countries, and a comparison of the performance of their community-based health plans could inform policymakers about ways to improve the quality of care., Objective: To compare the adherence to standards of care in Israel and in the USA., Study Design: An observational study comparing trends in performance using data from reports of the National Quality Measures Program in Israel and of the National Committee for Quality Assurance in the USA., Results: Differences in specifications preclude a comparison between most measures in the two reports. However, the comparison of 11 similar measures in the 2007 reports indicates that performance was higher in the USA by 10 or more percentage points on four measures (flu immunization, medication for asthma, screening for colorectal cancer and monitoring for diabetic nephropathy). Performance was higher in Israel on three measures in patients with diabetes (blood pressure, low-density lipoprotein (LDL) cholesterol and glycemic control), and similar on the remaining four measures. Between 2005 and 2007, quality of care improved in both countries. However, improvement was slower in the USA than in Israel., Conclusions: In comparison with the USA, Israel achieves comparable health maintenance organization (HMO) quality on several primary care indicators and more rapid quality improvement, despite its substantially lower level of expenditure. Considering the differences between the two countries in settings and populations, further research is needed to assess the causes, generalizability and policy implications of these findings.

Colorectal cancer (CRC) is an ideal target for early detection and prevention through screening. Noninvasive screening options are the guaiac fecal occult blood test and the fecal immunochemical test. Organized screening offers the promise of uniformly delivering screening to all members of a population who are eligible and due. Organized screening is defined as an explicit policy with defined age categories, method, and interval for screening in a defined target population with a defined implementation and quality assurance structure, and tracking of cancer in the population. The UK National Health Service; the Ontario, Canada Ministry of Health and Long-Term Care; and the US Veteran's Health Administration have used varied organized approaches to deliver guaiac fecal occult blood test screening to their populations. Kaiser Permanente Northern California began CRC screening in the 1960s, initially using flexible sigmoidoscopy. Implementation of organized fecal immunochemical test outreach was associated with improved Healthcare Effectiveness Data and Information Set CRC screening rates between 2005 and 2010 from 37% to 69% and from 41% to 78% in the commercial and Medicare populations, respectively. Organized fecal immunochemical test screening has been associated with an increase in annually detected CRCs, almost entirely because of increased detection of localized-stage cancers.

The provision of high quality healthcare is facilitated by an integrated team of multi-specialty physicians who are supported by an advanced electronic medical record. This paper shows how Kaiser Permanente of the Mid-Atlantic States is able to provide proactive care to members through physicians and their teams, integrated with functional health information technology systems.

Objective: To describe the team-based job improvement process that Primary Care Clinical Pharmacy Services (CPS) used to enhance teamwork and improve job satisfaction during a 4-year period., Setting: Health maintenance organization in Colorado from 2005 through 2008., Practice Description: Kaiser Permanente Colorado is a group model, not-forprofit health maintenance organization that provides health services to approximately 490,000 members. Highly integrated clinical pharmacy services are offered at each of its 17 primary care medical offices in the Denver-Boulder metropolitan area., Practice Innovation: A written survey consisting of three open-ended questions specifically directed at perceived positive and negative job-related features within Primary Care CPS was administered to team members. Six areas of focus emerged that were addressed by Primary Care CPS members within small groups., Main Outcome Measures: Pre- and postsurvey results from six identified focus areas were measured to address any impact of the team-based job improvement process., Results: Positive responses increased from baseline by 48% for communication, 42% for new employee orientation, 25% for teamwork, and 25% for Primary Care CPS meetings (P < 0.05; chi-square test). Positive responses related to clinical practice increased 22%; however, this did not reach statistical significance. Perceived satisfaction with the documentation system for tracking clinical interventions declined 11% from baseline., Conclusion: Based on the initial successes with surveys and small-group discussions, Primary Care CPS continues to use this team-based job improvement process to resolve concerns or share best practices.

Recruitment of participants to clinical trials remains a significant challenge, especially for research addressing topics of a sensitive nature such as fecal incontinence (FI). In the Fiber Study, a randomized controlled trial on symptom management for FI, we successfully enrolled 189 community-living adults through collaborations with specialty-based and community-based settings, each employing methods tailored to the organizational characteristics of their site. Results show that using the two settings increased racial and ethnic diversity of the sample and inclusion of informal caregivers. There were no differential effects on enrollment, final eligibility, or completion of protocol by site. Strategic collaborations with complementary sites can achieve sample recruitment goals for clinical trials on topics that are sensitive or known to be underreported., (Copyright © 2010 Wiley Periodicals, Inc.)

This study compares the use of acute psychiatric hospitalization; selected outcomes, including rehospitalization; as well as costs associated with the health maintenance organization (HMO), carve-out, and fee-for-service models as implemented in the Massachusetts Medicaid program between FY1994 and FY2000. This is a longitudinal analysis that primarily uses unduplicated individual data from the Massachusetts Case Mix database. Analyses focus on 56,518 individuals who were psychiatrically hospitalized on acute units within 57 hospitals. They employ Cox regression to compare rehospitalization among the three programs. The hypotheses were strongly supported: HMOs have the most substantial impacts in minimizing service provision, with the carve-out program having an impact intermediate between the HMO and fee-for-service programs. Lower utilization rates were associated with lower overall rates of hospitalization, shorter lengths of stay, fewer repeated stays, and less geographic access and greater displacement of psychiatric patients to medical units. The final model of rehospitalization has an overall predictive accuracy of 59.6%.

Variation in the use of hospital and physician services among Medicare beneficiaries is well documented. However, less is known about the younger, commercially insured population. Using data from the Community Tracking Study to investigate this issue, we found significant variation in the use of both inpatient and outpatient services across twelve metropolitan areas. HMO insurance reduces, but does not eliminate, the extent of this variation. Our results suggest that health plan spending to better organize delivery systems and manage care may be efficient, and regulations that arbitrarily cap plans' spending on administration, such as minimum medical loss ratios, could undermine efforts to achieve better value in health care.

Background: Comprehensiveness, a defining feature of primary care (PC) is associated with patient satisfaction and improved health status. This paper evaluates comprehensive services in fee-for-service (FFS), Health Service Organizations (HSOs), Family Health Networks (FHNs) and Community Health Centres (CHCs) payment models in Ontario., Objectives: To assess how organizational models of PC differ in the delivery of comprehensive services and which organizational factors predict comprehensive PC delivery., Methods: Cross-sectional mixed-method study with nested qualitative case studies., Setting: PC practices in Ontario., Participants: One hundred and thirty-seven PC practices (35 FFS, 32 HSO, 35 FHN and 35 CHC) and 358 providers., Instruments: Surveys based on the Primary Care Assessment Tool and qualitative interviews., Outcome Measures: Comprehensiveness scores were calculated from practice report of clinical services offered in women's health, psychosocial counselling, procedural and diagnostic services. Confounding variables were calculated from provider and patient surveys. Performance at a model level was compared using analysis of variance. Multiple regressions then established factors independently associated with comprehensiveness., Results: CHCs offered significantly more comprehensive services (74%) than other models (61%-63%; P < 0.005). Thirty-five per cent of the variance in comprehensiveness was explained by a regression model that included the number of family physicians working at the practice, presence of other allied health providers, rurality and length of practice operation., Conclusions: Practice size and diversity of providers seemed to partially explain the better performance of CHCs. Practice setting and, probably, practice maturity are significant drivers in the provision of comprehensive PC services. These factors warrant further examination in other PC environments.

For the past decade, the high-quality, relatively low-cost health care delivered in Grand Junction, Colorado, has led that community to outperform most others in the United States. Medicare patients in Grand Junction have fewer hospitalizations, shorter hospitalizations, and lower mortality rates after hospitalization than do Medicare patients in comparison hospitals. Effective, efficient care is delivered in Grand Junction through separate, self-governing organizations that perceive health care as a community resource. This article describes how the various stakeholders in Grand Junction have addressed problems and set standards for the system. The lessons could apply to broader health reform efforts in communities around the country.

Key findings. (1) An increase in commercial plan penetration increased the liklihood [sic] that a physician would accept new Medicaid patients, but this did not significantly impact enrollee costs. (2) An increase in Medicaid-dominant HMO market penetration increased the probability that individuals reported using the ED as their primary source of care.

Telephone advice nursing (TAN) is part of a current effort to improve patient access while reducing cost and encouraging self-care. However, the environment in which TAN occurs can significantly affect both nurse and patient outcomes. This research builds on findings from a large health maintenance organization study by Valanis et al. in which questionnaires and call descriptions were used to correlate TAN nurse and caller/patient perceptions of calls at three regional sites. The survey tools were used to identify nurse perceptions of their work environments (WEs) as well as caller perceptions of using the advice service. The sample included 88 nurse questionnaires and 865 caller questionnaires. Multivariate analysis of covariance revealed significant site perception differences in the WE of stress, communication, and autonomy, whereas no significant differences were noted in collegial relationships and organizational support. Each site was also determined to be a unique predictor of patient perceptions of satisfaction with the advice. Findings indicate nursing professionals act as a filter to mask stressful WE effects experienced by nurses and ensure patient outcomes thereby supporting patient satisfaction with the service.

Objective: To assess pragmatic challenges faced when implementing, delivering, and sustaining models of integrated mental health intervention in primary care settings. Thirty percent of primary care patients with chronic medical conditions and up to 80% of those with health complexity have mental health comorbidity, yet primary care clinics rarely include onsite mental health professionals and only one in eight patients receive evidence-based mental health treatment. Integrating specialty mental health into primary care improves outcomes for patients with common disorders, such as depression., Methods: We used key informant interviews documenting barriers to implementation and components that inhibited or enhanced operational success at 11 nationally established integrated physical and mental condition primary care programs., Results: All but one key informant indicated that the greatest barrier to the creation and sustainability of integrated mental condition care in primary care settings was financial challenges introduced by segregated physical and mental health reimbursement practices. For integrated physical and mental health program initiation and outcome changing care to be successful, key components included a clinical and administrative champion-led culture shift, which valued an outcome orientation; cross-disciplinary training and accountability; use of care managers; consolidated clinical record systems; a multidisease, total population focus; and active, respectful coordination of colocated interdisciplinary clinical services., Conclusions: Correction of disparate physical and mental health reimbursement practices is an important activity in the development of sustainable integrated physical and mental condition care in primary care settings, such as a medical home. Multiple clinical, administrative, and economic factors contribute to operational success.

The conventional wisdom is that managed care's brief life is over and we are now in a post-managed care era. In fact, managed care has a long history and continues to thrive. Writers also often assume that managed care is a fixed thing. They overlook that managed care has evolved and neglect to examine the role that it plays in the health system. Furthermore, private actors and the state have used managed care tools to promote diverse goals. These include the following: increasing access to medical care; restricting physician entrepreneurialism; challenging professional control over the medical economy; curbing medical spending; managing medical practice and markets; furthering the growth of medical markets and private insurance; promoting for-profit medical facilities and insurers; earning bounties for reducing medical expenditures: and reducing governmental responsibility for, and oversight of, medical care. Struggles over these competing goals spurred the metamorphosis of managed care. This article explores how managed care transformed physicians' conflicts of interests and responses to them. It also examines how managed care altered the opportunities for patients/medical consumers to use exit and voice to spur change.

Objectives: To determine the effect of a Social Health Maintenance Organization (S/HMO) on diverting older adults admitted into a nursing facility from converting to long-stay placement., Design: Members of the SCAN S/HMO and those in Medicare Fee-For-Service were compared on successful discharge to the community after being admitted to nursing facilities between January 1, 2001, and December 31, 2003., Setting: Skilled nursing facilities in 4 counties in Southern California (Los Angeles, Orange, San Bernardino, Riverside)., Participants: Data (N = 4635) were extracted from Minimum Data Set (MDS) 2.0 records for nursing facility residents in the S/HMO or the Medicare Fee-for-Service 5% sample who were aged 65 and older with an episode of care greater than 14 days., Measurements: Predisposing, enabling, and need measures were used to predict successful discharge to the community within 90 days., Results: After controlling for selected sociodemographics, comorbidities, behavioral issues, mental health conditions, and other risk factors, being enrolled in the S/HMO increased the likelihood of successful discharge by 26%., Conclusion: With systemic increases in short-stay patients, research on diversion must look past the avoidance of unnecessary entry to nursing facilities, to the successful transition of short-stay residents to the community. As described in this study, the S/HMO model is an important but largely unaddressed method of avoiding the conversion to long-stay., (Copyright 2010 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.)

Heart failure case management programs have been shown in clinical trials to be highly effective at preventing future hospitalizations. But the absolute benefits of these programs depend on the baseline risk of outcome in the treated population. Because baseline risks of hospitalization in trials are often higher than community-based samples, translating trial results to the community setting may be misleading. One solution is to identify subgroups for intervention that have sufficiently high baseline risk. Using estimates of hospitalizations averted from a previously published systematic review of heart failure management, we estimated a program's efficiency based on level of predicted risk. Medical history and demographic data on heart failure patients from a large integrated US health plan were used to build a logistic regression-based prognostic risk score for cardiovascular-related hospitalization over 1 year. We calculated the crude rate of hospitalizations for comparison with trial data. We also calculated the program's potential dollar savings from averting hospitalizations. The average risk of hospitalization in the systematic review's trials was 45%; our population's average observed risk was 18% and the risk among the highest risk patients was 33%. After accounting for the assumed annual intervention cost of $700, the base-case analysis (at $6000 per hospitalization) shows a savings of $122/patient at highest risk; failing to intervene according to predicted risk (no targeting) would actually cost $211/patient. Our findings illustrate how clinical trial findings can be efficiently integrated into community settings by using a prognostic risk score to focus attention on high-risk subgroups.

As the patient-centered medical home model emerges as a key vehicle to improve the quality of health care and to control costs, the experience of Seattle-based Group Health Cooperative with its medical home pilot takes on added importance. This paper examines the effects of the medical home prototype on patients' experiences, quality, burnout of clinicians, and total costs at twenty-one to twenty-four months after implementation. The results show improvements in patients' experiences, quality, and clinician burnout through two years. Compared to other Group Health clinics, patients in the medical home experienced 29 percent fewer emergency visits and 6 percent fewer hospitalizations. We estimate total savings of $10.3 per patient per month twenty-one months into the pilot. We offer an operational blueprint and policy recommendations for adoption in other health care settings.

Background: Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system., Methods: Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models., Results: More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration., Conclusions: More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.

Maccabi Healthcare Services (MHS), the second largest HMO in Israel, has chosen to implement a multi-annual strategy to promote equality and equity in healthcare. Within the strategy's framework, MHS will maintain an ongoing process of studying the variability of its members characteristics for the purpose of adjusting service provision and improving health outcomes. MHS has recently published its first Equality Report, dedicated to defining the observed associations between its members demographic and socioeconomic characteristics and their health measures. The report identifies those sub-groups belonging to Israel's geographic and social peripheries that require focused interventions. Based on the report's recommendations, MHS has decided to designate promotion of equality as its strategic objective, a filter through which every policy decision will be reviewed. In addition it was decided to: 1. develop an organizational methodology to produce an index to assess reductions in disparities over time; 2. adjust MHS services to member's ethnic and cultural needs; 3. strengthen perceptions of community orientation based in primary care; 4. target resources to "social peripheries", beginning in 2010; 5. improve service accessibility and availability in geographically peripheral areas; 6. reduce economic barriers to healthcare. This article details the disparities as analyzed in the report in addition to the specific policy decisions made in their wake.

Objective: To determinate the clarity, relevance and per tinence of a primary health care evaluation strategy for different Latin American health sub-systems., Material and Methods: This strategy was assessed using workshops held with decision makers and administrative managers from a public health organization, a social insurance and a private insurance health organization. The study took place in the province of Santa Fe (Argentina) between May 2006 and May 2007., Results: The strategy was determined to be clear and relevant by all organizations, but highly applicable only in the public case. The social-insurance and private cases questioned the pertinence of objectives related to community participation, intersectoral actions and a focus on social determinants of health, in addition to considering it necessary to restrict the scope of ideas related to universal access and equity with regard to their client population., Discussion: The evaluation of the pertinence of the strategy was explained by the particularities of the institutional context, as well as the goals and survival strategies used by each organization.

Background: Based on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative care (IPC). Within one year, the number of IPC consultations program-wide increased almost tenfold from baseline, and the number of teams nearly doubled. We report here results from a qualitative evaluation of the IPC initiative after a year of implementation; our purpose was to understand factors supporting or impeding the rapid and consistent spread of a complex program., Methods: Quality improvement study using a case study design and qualitative analysis of in-depth semi-structured interviews with 36 national, regional, and local leaders., Results: Compelling evidence of impacts on patient satisfaction and quality of care generated 'pull' among adopters, expressed as a remarkably high degree of conviction about the value of the model. Broad leadership agreement gave rise to sponsorship and support that permeated the organization. A robust social network promoted knowledge exchange and built on an existing network with a strong interest in palliative care. Resource constraints, pre-existing programs of a different model, and ambiguous accountability for implementation impeded spread., Conclusions: A complex, hospital-based, interdisciplinary intervention in a large health care organization spread rapidly due to a synergy between organizational 'push' strategies and grassroots-level pull. The combination of push and pull may be especially important when the organizational context or the practice to be spread is complex.

Our healthcare system is fragmented, with a misalignment of incentives, or lack of coordination, that spawns inefficient allocation of resources. Fragmentation adversely impacts quality, cost, and outcomes. Eliminating waste from unnecessary, unsafe care is crucial for improving quality and reducing costs--and making the system financially sustainable. Many believe this can be achieved through greater integration of healthcare delivery, more specifically via integrated delivery systems (IDSs). An IDS is an organized, coordinated, and collaborative network that links various healthcare providers to provide a coordinated, vertical continuum of services to a particular patient population or community. It is also accountable, both clinically and fiscally, for the clinical outcomes and health status of the population or community served, and has systems in place to manage and improve them. The marketplace already contains numerous styles and degrees of integration, ranging from Kaiser Permanente-style full integration, to more loosely organized individual practice associations, to public-private partnerships. Evidence suggests that IDSs can improve healthcare quality, improve outcomes, and reduce costs--especially for patients with complex needs--if properly implemented and coordinated. No single approach or public policy will fix the fragmented healthcare system, but IDSs represent an important step in the right direction.

Clinical guidelines for the care of patients with progressive chronic kidney disease (CKD) have been developed by a broad range of organizations within the kidney community. Despite consensus among these guidelines and significant effort on the part of federal agencies, voluntary health organizations, and professional groups, existing data suggest that much work remains to achieve acceptable levels of recommended care. Several small studies have described CKD interventions to improve outcomes, but there are few examples of large-scale attempts to improve CKD care in a systematic way. Southern California Kaiser Permanente has developed a population management approach to CKD in a health maintenance organization setting that has improved outcomes. The Indian Health Service, an agency of the Public Health Service that provides direct care to American Indians and Alaska Natives, has enhanced its diabetes care delivery system to address the renal complications of diabetes. This effort may explain a significant decrease in the incidence rate of ESRD among American Indians with diabetes. Because much of the burden of CKD falls on ethnic and racial groups with decreased access to care, enhancing CKD care in the primary setting may offer the best opportunity to improve outcomes. The National Kidney Disease Education Program in collaboration with community heath centers has developed a model to improve outcomes through application of the chronic care model to CKD management in primary settings that serve high-risk populations.

This case study (n=41,969) aims to discover managerially useful predictors of multiple switching among HMOs in a Medicaid managed care population observed over 33 months. Cox's proportional hazards model was used to analyze eligibility data for the entire population, claims data for Medicaid services received during six months prior to HMO enrollment (sample n=2,474) and telephone interviews (sample n=656). Each analytic stage involved four comparisons: (1) enrollees with one switch compared with enrollees with no switches; (2) enrollees with multiple switches compared with those having no switches; (3) in relation to making the first switch, enrollees with multiple switches compared with those having one switch; and (4) in relation to making the second switch, multiple compared with those having one switch. Interruptions (which were independent of switches) predicted switching versus non-switching. Medical claims and, weakly, greater age were associated with multiple switching. Managers can use these three predictors to reduce switching and multiple switching. The finding that switching was associated with greater utilization before HMO enrollment contradicts findings for employer-sponsored insurance, but a possible explanation is offered.

Objective: To develop and implement a continuing pharmacy education (CPE) program at Kaiser Permanente Colorado (KPCO) DESIGN: To address the continuing education needs of its diverse pharmacy staff, an internal continuing pharmacy education (CPE) program was developed. The pharmacy department became an accredited provider by the Accreditation Council for Pharmacy Education (ACPE). Live, interactive, and evidence-based CPE programs, presented by highly qualified internal staff members, utilized videoconferencing and a Web-based learning management system. Cross-accreditation of medical and pharmacy educational programs was offered to KPCO staff members., Assessment: Annual needs assessments were conducted to ensure the provision of relevant educational topics and to assess learning needs. To demonstrate outcomes of the CPE programs, 2 methods were utilized: objective effectiveness assessment and knowledge acquisition assessment. This program met the objectives for CPE activities a large majority of the time (usually over 90%), demonstrated statistically significant (p < 0.05) improvement in knowledge from before to after the CPE activity in 11 of 13 questions asked, and minimized the cost to acquire CPE credit for both the pharmacy department and its staff members., Conclusion: The KPCO continuing pharmacy education program has developed a high quality and cost-favorable system that has resulted in significant improvements in attendee knowledge.

Objective: To evaluate whether patients with coronary artery disease (CAD) discharged from the Clinical Pharmacy Cardiac Risk Service (CPCRS) would maintain their lipid goals with use of an electronic laboratory reminder system., Study Design: A 2-year, randomized study at Kaiser Permanente Colorado., Methods: Patients with prior CAD (acute myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention) who had been enrolled in the CPCRS for at least 1 year and who had 2 consecutive low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol, and blood pressure readings at goal within 6 months before enrollment were randomized to remain in the CPCRS (CPCRS care) or to receive usual care from primary care physicians plus laboratory reminder letters (usual care). The primary outcome was maintenance of LDL-C goal at study end. The t test and chi(2) test of association were used to assess differences in mean and categorical values, respectively., Results: A total of 421 patients (214 CPCRS care, 207 usual care) were randomized. Their mean age was 72 years; 74% were male. After 1.7 years of follow-up, the proportions of patients maintaining their LDL-C goal of <100 mg/dL were 91% and 93.1% in the CPCRS care and usual care groups, respectively (P = .46). The proportions maintaining their LDL-C goal of <70 mg/dL were 68.6% and 56.8% in the CPCRS care and usual care groups, respectively (P = .23)., Conclusion: This study demonstrated that LDL-C measures can remain controlled in most patients discharged from a cardiac disease management program.

Objective: The goal was to evaluate the feasibility and acceptance of a new model for well-child care (WCC) in a large health maintenance organization., Methods: We designed a new model of WCC that engages families in Internet-based developmental and behavioral screening, allows for review of the results before the visit, and allows for selection of the appropriate visit type (e-visit, e-visit with brief provider visit, or extended encounter). The new model was pilot-tested in 2 practices within a large health maintenance organization. Seven providers and 70 parents participated in the study. Parents and providers were surveyed regarding their experience and satisfaction with the encounter., Results: Seventy-five percent of parents thought that the online previsit assessment improved or very much improved the WCC visit. However, 12% of parents found the online assessment somewhat or very difficult to use. All of the parents found the e-visit or the e-visit with brief provider visit acceptable or very acceptable, compared with a standard WCC visit. All 7 providers thought that use of the new model helped focus the visit and that they would continue or definitely continue to use the model., Conclusions: We demonstrated the feasibility of a new model of WCC that engaged parents in previsit assessment and used alternative visit types to tailor care to the needs of the family. Future research will be needed to examine the impact of this model on important WCC outcomes.

Premature morbidity and mortality from chronic diseases account for a major proportion of expenditures for health care cost in the United States. The purpose of this study was to measure the effects of a disease management program on physiological and behavioral health indicators for Medicaid patients in Florida. A two-year prospective study of 15,275 patients with one or more chronic illnesses (congestive heart failure, hypertension, diabetes, or asthma) was undertaken. Control of hypertension improved from baseline to Year 1 (adjusted odds ratio = 1.60, p < .05), with maintenance at Year 2. Adjusted cholesterol declined by 6.41 mg/dl from baseline to Year 1 and by 12.41 mg/dl (p < .01) from baseline to Year 2. Adjusted average medication compliance increased by 0.19 points (p < .01) in Year 1 and 0.29 points (p < .01) in Year 2. Patients in the disease management program benefited in terms of controlling hypertension, asthma symptoms, and cholesterol and blood glucose levels.

Purpose: Active surveillance of population-based health networks may improve the timeliness of detection of adverse events (AEs). Our objective was to expand our previous signal detection work by investigating the effect on signal detection of alternative study specifications., Methods: We compared the signal detection performance under various study specifications using historical data from nine health plans involved in the HMO Research Network's Center for Education and Research on Therapeutics (CERT). Five drug-event pairs representing generally accepted associations with an AE and two pairs representing "negative controls" were analyzed. Alternative study specifications related to the definition of incident users and incident AEs were assessed and compared to our previous findings., Results: Relaxing the incident AE exclusion criteria by (1) including members with prior outpatient diagnoses of interest and (2) halving (to 90 days) the time window specified to define incident exposure and diagnoses increased the number of members under surveillance and as a consequence increased the number of exposed days and diagnoses by about 10-20%. The alternative specifications tend to result in earlier signal detection by 10-16 months, a likely consequence of more exposures and events entering the analysis., Conclusions: This paper provides additional preliminary information related to conducting prospective safety monitoring using health plan data and sequential analytic methods. Our findings support continued investigation of using health plan data and sequential analytic methods as a potentially important contribution to active drug safety surveillance., ((c) 2009 John Wiley & Sons, Ltd.)

Progress in medicine and the subsequent extension of health coverage has meant that health expenditure has increased sharply in Western countries. In the United States, this rise was precipitated in the 1980s, compounded by an increase in drug consumption which prompted the government to re-examine its financial support to care delivery, most notably in hospital care and emergencies services. In California for example, 50 emergency service providers were closed between 1990 and 2000, and nine in 1999-2000 alone. In that State, only 355 hospitals (out of 568) have maintained emergency services departments (Darves, WebMB, 2001). Reforming hospital Emergency Department (ED) operations requires caution not only because the media pay a lot of attention to ED operations, but also because it raises ethical issues: this became more apparent with the enactment of the EMTALA which stipulates that federally funded hospitals are required to give emergency aid in order to "stabilize" a patient suffering from an "emergency medical condition" before discharging or transferring that patient to another facility. While in essence the law aims to preserve patient access to care, physicians assert that the EMTALA leads to more patients seeking care for non-urgent conditions in EDs (GAO, Report to Congressional Committees, 2001), leading to overcrowding, delayed care for patients with true emergency needs, and forcing hospitals to divert ambulances to other facilities resulting in further delays in urgent care. Also, fewer physicians are willing to be on-call in emergency departments because the EMTALA law requires on-call physicians to provide uncompensated care. Thus there is a need to find a balance between appropriate care to be provided to ED patients, and low costs since uncompensated care is not covered by state or federal funds. This concerns, first and foremost, hospitals that provide a greater amount of uncompensated care (e.g. hospitals serving communities with a higher population of illegal immigrants). Looking at the intrinsic causes of high ED costs, the paper first explains why costs of care provided in EDs are high, and look at a major cause of high ED costs: overcrowding and ED users' characteristics. This is followed by a discussion on a much-debated factor: the use of EDs for non-emergency conditions, a practice which has often been accused of disproportionately raising costs. We look at various mechanisms used either to divert or prevent the patient from using ED: these include triage services; and the role of HMOs in the ED chain of care: though the US government has increasingly relied on Managed Care organizations to contain costs (e.g. Medicaid and Medicare Managed Care), do HMOs make a difference when it comes to ED costs? Of particular interest is the family physician acting as a gatekeeper, and the legislation that was enacted to protect those who bypass the referral system. We then look at the other end of the ED chain (i.e. the recipient): the financial responsibility of ED users has increased. Alternative providers such as walk-in clinics are increasingly common. EDs also attempt to reengineer their operations to curb costs. While the data are mostly applicable to a private health care system (e.g. the US), the article, using a critical assessment of the existing literature, has implications for other EDs generally, wherever they operate, since every ED faces similar funding problems.

This study examines the effect of health maintenance organizations (HMOs) and for-profit HMO share on the survival of safety net services in hospitals between 1990 and 2004. The primary data sources are the American Hospital Association Annual Surveys, the Medicare hospital cost reports, and the HMO enrollment and ownership data from Interstudy. I analyze the risks of shutting down each safety net service separately using the proportional hazard models. I find that the risks of shutting down hospital safety net services do not vary by different levels of overall HMO penetration. However, conditional on the overall HMO penetration level, increasing for-profit presence of HMO does increase the risks of shutting down several safety net services. Policies evaluating the for-profit expansion or ownership conversion of health plans should take this potential adverse effect into consideration.

Participant satisfaction is an important outcome in evaluating the effectiveness of healthcare programs and benefits. With vulnerable populations, such as Medicaid beneficiaries, determining participant satisfaction poses unique challenges. The purpose of this article is to discuss participant satisfaction methods and outcomes from a multi-year experience of surveying Medicaid Managed Care (MMC) participants in Nebraska (2000-2005). Using a variety of survey methods, the foci were to measure satisfaction with MMC enrollment, understanding of MMC guidelines, and satisfaction with education services provided. Results illustrate response rate patterns and outcome trends that contribute to quality improvement knowledge useful for others surveying Medicaid populations.

Objectives: To report on the creation of a leadership development program targeted exclusively at pharmacists working in management in the professional community., Setting: Large staff-model health maintenance organization (HMO) in California between 2004 and 2008., Practice Description: The Pharmacy Leadership Institute (PLI; a joint effort of the School of Pharmacy and the Center for the Health Professions at the University of California, San Francisco) tested a program in a large staff-model HMO with hundreds of pharmacists in leadership roles. This program included learning seminars, psychometric assessments, leadership goals, intersession activities, coaching/mentoring, and leadership projects., Practice Innovation: Not applicable., Main Outcome Measures: PLI collected survey data in order to evaluate the effectiveness of the institute's leadership development program. In addition, an external evaluator was hired to conduct interviews with the pharmacy directors of the organization which chose to pilot the program., Results: The evaluations from the participants indicate that the leadership development program met many but not all of its initial objectives. Consistent with action research methodology, the faculty of the institute met to redesign some sections of the program in order to meet the established goals. Adjustments were made to different components of the program over the next 4 years. Evaluation data show that these revisions were successful. In addition, follow-up evaluations with participants showed a lasting impact of the program on both individual leadership skills and organizational outcomes., Conclusion: Given the positive outcomes indicated by the evaluation data used in this study, the work of PLI indicates that broader leadership skills can be identified and enhanced within a group of pharmacy managers.